It is known formally as an Act 33 Fatality Review report. The bureaucratic terminology belies the heartbreak within.
Over several pages, in stark, clinical language, a narrative of tragedy emerges. Children are tortured, shot, stabbed, burned with blow torches, and left unwatched in filth-filled, decrepit homes.
Infants are found face down in bathtubs or rolled over and suffocated as they sleep. Others are simply ignored.
At the heart of each tale is an attempt to show what the city's Department of Human Services did or didn't do prior to those tragedies in hopes of better protecting vulnerable children in the future.
"They are the only public window into what the department does," said Richard Gelles, former dean of the School of Social Policy and Practice at the University of Pennsylvania. "Much of what's contained in the Act 33 reports reflects on what should be done to address overarching problems. . . . I think the department has a lot to learn from Act 33. I think a lot more can be done with them."
Mandated by a 2008 state law, the reviews are conducted by a team of doctors, nurses, detectives, psychologists, and DHS staffers. The team has made 156 recommendations to improve DHS's handling of children. While most have been adopted, progress is slow in the growing agency and some of the hardest problems remain unsolved.
An Inquirer review of the reports found that a child's death or serious injury is often preceded by multiple reports of mistreatment or bizarre or criminal behavior by a caregiver. While social workers often are unable to verify those reports, their very existence serves as a red flag for trouble ahead.
Since the advent of the Act 33 system, 40 children have died while under DHS watch. (DHS has oversight of more than 6,000 children.) Those deaths were preceded by 143 reports of abuse or neglect. Of those, 58 were substantiated and some action was taken. Despite that, children still fell through the cracks.
During the same period, another 40 children suffered near-fatal injuries from abuse or neglect. In those cases, DHS had received 119 prior reports, 56 substantiated.
"It's completely frustrating when you see the family has a huge number of histories" and nothing was done, said Jessica Shapiro, acting commissioner of DHS. "It could mean we never picked it up and we should have or it could mean [evidence of abuse] wasn't there at the time."
Red flag system
DHS's existing red-flag protocol followed a recommendation from the Act 33 team that took four years to implement.
In March 2009, twin toddlers were badly burned when they were placed in a bathtub with excessively hot water by their mother's boyfriend. One boy was critically injured, with second- and third-degree burns from his waist down. Bruises covered both boys' bodies.
The Act 33 team found that, leading up to the occurrence, there had been a series of worrying, but unfounded, reports, including that the home was infested with rats and roaches and lacked food, and that the children's mother was overwhelmed and suicidal.
"DHS should have a system that would trigger a closer review of a case when there has been a series of unsubstantiated reports," the Act 33 team wrote at the time.
The recommendation became policy in 2013. DHS now requires additional review when the agency receives six or more reports of problems - founded or unfounded - within six months.
The Act 33 team has concluded even that is not enough.
In 2014, an infant was hospitalized after nearly drowning in a bath. The family had six prior reports, including allegations the mother was using crack, children were not attending school, and one had ingested charcoal-lighter fluid.
The case was not flagged because the calls came in over more than six months. As a result, the Act 33 team recommended DHS "reexamine its criteria for the review of high-activity cases."
Two years later, a revised protocol is still in development. Shapiro said a new electronic case management system will include automated alerts in cases with multiple prior reports. How many and over what time period are still being determined.
That system won't be in place until December 2018, said Shapiro, who hopes to accelerate that process.
In a number of reports, Act 33 investigators specifically pointed to just plain sloppy casework.
In 2013, 3-month-old Samuel Cabrera was punched to death by his father. The infant's internal organs were crushed as if he had been in a car crash. Samuel's father is serving 20 to 40 years in prison for the boy's death.
The parents had six prior reports, four substantiated. Social workers missed that the family had a history with children's services in New Jersey. The mother was on probation for child abuse there and was not supposed to be living with the children.
"It appears the case history was not reviewed during the course of this investigation," the Act 33 team said.
A similar failure was found in the June 2015 case of 21/2-month-old Tymir Smith, who was born addicted to methadone and killed, authorities believe, when his mother rolled over on him while they slept together.
Caseworkers did not complete a safety assessment of the home and were unaware that Tymir's mother had already lost custody of another child.
In several instances, children suffered as a result of miscommunication within DHS or with other counties or contractors.
This spring, 10-year-old Ethan Okula died after a series of missed opportunities. Okula was intellectually impaired and had medical problems, including a bowel obstruction that ultimately killed him after his repeated complaints of a stomachache went unaddressed.
The child's case was transferred from DHS to a contractor, creating confusion at times for caseworkers, who were unaware that Okula had missed a number of medical appointments.
Sam Gulino, the city's chief medical examiner and chair of the Act 33 review team, said children are most vulnerable during these "handoffs."
Given that more than 6,000 cases have transitioned from DHS to the private providers for frontline case management, there has been a lot of opportunity for error.
On the whole, Gulino said, the department has improved by leaps and bounds since the Act 33 team he voluntarily chairs started eight years ago.
"We are unflinching," Gulino said. "Never have we felt there's pressure to make it look sunny when it's not."
Gulino said DHS senior staff members often attend the meetings and want a full account of what happened.
"I'm a believer in this process. I believe it has changed DHS and it can continue to change DHS."
Since 2009, Act 33 team recommendations have led to systemwide changes, including staff training on properly interpreting criminal records and a detailed policy on when caseworkers must consult psychologists or lawyers.
Additional nurses were hired after a recommendation that social workers needed more medical guidance when working with sick children.
The agency is currently dealing with a huge influx of children, sparked over the last three years by changes in mandatory child-abuse reporting laws. That means more cases per caseworker and greater potential for errors and missed warning signs.
The city is not shying from self-critique. Last month, the department selected a firm to review the agency, as Mayor Kenney requested.
Meanwhile, the state has launched a panel to look at child fatalities and near-fatalities statewide.
The panel aims to go deeper into the reports to identify trends across counties.
"We want to look at prior agency involvement, but also what other systems and services touch these families," said Cathy Utz, the state's deputy secretary for youth and families. "Other risk factors, family environment, education level, to see what we can learn."
Cathleen Palm, founder of the Center for Children's Justice, questioned why the state hadn't launched a more comprehensive review sooner.
"We've essentially lost eight years," she said. "You asked a lot of people to jump through hoops, get in a room, make these recommendations, to what end? If all that happens is we dump them on a website then nothing changes."